- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,981.07 / $7,762.47
| Facility | | $3,388.44 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $1,778.28 / $7,413.10
| Professional | | $169.82 | $1,778.28 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $9,332.54 / $10,964.78
| Facility | | $5,370.32 | $9,332.54 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,848.93 / $16,982.44 / $17,782.79
| Facility | | $15,848.93 | $16,982.44 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,258.93 / $2,951.21
| Professional | | $602.56 | $1,258.93 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,548.13 / $10,715.19
| Facility | | $1,258.93 | $3,548.13 | $10,715.19 |